3618_ML&P_SalesCatalog_Web

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Our variety of manual forms come Edge Clued or Snap-a-part with 2-5 parts. 1 or 2 sided printing is also available. Standard 20# Carbonless • Standard Color Sequence (2-4 Parts) White, Canary, Pink & Gold • Standard Color Sequence (5 Parts) White, green, Canary, Pink & Gold • Standard Ink Colors Black, Reflex Blue, 347 Green, 208 Burgundy, 032 Red & 185 Red (All other Pantone colors available at additional cost) • Additional Services Available - Wrap Around Covers - 1, 2, 3 & 4 spot color printing - Padding, Drilling & Numbering

COPIES #

1a. FIRSTNAME

1b. MIDDLENAME

1c. LASTNAME

1d. JR.,etc.

2. DATEOFDEATH (Mo,Dy, yr)

3. SEX 4. SOCIALSECURITYNUMBER 5a. AGE (Yrs) 5b. UNDER1YEAR 5c. UNDER 1DAY 6. DATEOFBIRTH (Mo,Dy,Yr) Months Days Hours Minutes

LastBirthday

7. BIRTHPLACE (City andState orForeignCountry)

8. WASDECEDENT 9.PLACEOFDEATH (Check onlyone) EVER INU.S. YES HOSPITAL: DOA

OTHER:

NursingHome Residence

ARMEDFORCES? NO Inpatient ER/Outpatient Other (Specify)

HobbsSouthPortland

10. FACILITYNAME (If not institution,give street andnumber)

11.COUNTYOFDEATH 12. CITYORTOWNOFDEATH

13. MARITALSTATUS 14. MOSTRECENTSPOUCE (Ifwife,

15. DECEDENT’SUSUALOCCUPATION (Give kind ofwork 16. KINDOFBUSINESS / INDUSTRY FUNERAL ARRANGEMENTS doneduringmost ofworking life. Donot use retired.) 19. RACE -American Indian,Black,White,etc. (Specify)

DECEDENT PARENTS INFORMANT FATHER’S MOTHER’S

givemaiden name)

Married NeverMarried Living Deceased Widowed Divorced 17. DECEDENT’SEDUCATION (Specify onlyhighestgrade completed) 18. ANCESTRY -French,English, Irish,etc. (Specify)

Elementary/Secondary College (0 - 12grades) (1 - 4 or 5+ years) 20. RESIDENCESTATE 21. RESIDENCECOUNTY 22. RESIDENCECITYORTOWN

23. RESIDENCESTREETANDNUMBER

Name: DateofDeath:

24d. JR., etc. File #: MortuaryTrust ID: Amount:

24a. FIRSTNAME

24b. MIDDLENAME 24c. LASTNAME

Time:

25a. FIRSTNAME

25b. MIDDLENAME

25c. MAIDENSURNAME

PlaceofDeath:

26. INFORMANT -NAME (Type orPrint)

27. MAILINGADDRESS (Street andNumber orRuralRouteNumber,CityorTown, State, ZIPCode)

28. RELATION

29. T.O.D.

30. PHONE

¨ NO Director: Zip:

Residence:

31. METHODOFDISPOSITION: ¨ Temporary

¨ Burial

¨ Cremation

¨ Removal

¨ UsebyMedical

¨ Other (Specify)

32. WASBODYEMBALMED

Storage

FromState Science

¨ YES

33b. LOCATION (City,Town,State) City: State:

33a. PLACEOFDISPOSITION (Name ofCemetery,Crematory,orOtherPlace)

33c.DATEOFDISPOSTION (Mo.Dy.Yr.)

Informant:

Phone:

Biographical Information Name &Age Address:

Relationship:

City: State:

Zip:

Place of Birth:

Parents: Schooling:

Military: Service Details: Funeral Memorial Graveside Public Private None Visitation: Service: Reception: Burial: Date Day Time Place Date Day Time Place Date Day Time Place

Employment History:

Date

Day

Time

Place

ReligiousAffilation:

Church:

Arrangements

Disposition: Cremation Burial Tomb

Need

Done

Physician: Phone #: Fax #:

Clubs & Organizations: Hobbies: Predeceased by: Survivors: In Lieu of Flowers:

Church: Clergy: Casket: Open / Closed Vault: Urn: Flowers: Hairdresser: Organist: Sexton: Reg.Book: PrayerCards: Prayer:

EDRS File #: MERelease

Veterans Branch ofService:

Flag Honors

Marker Benefits

Obituary/Notice: Photo /NoPhoto Date toRun

Notice: Paper:

Reception Hostess: Caterer: FoodOrder:

WindhamFireRescueDepartment 375GrayRoad Windham,Maine 04062 Tele # (207) 892-1911 Fax # (207) 892-0544 FireAlarmDetection&SuppressionActivationReport

WindhamFire -RescueDepartment 375GrayRoad Windham,ME 04062 WindhamFire -Rescu Department 375GrayRoad Windham,ME 04062

Date:___________ Incident#_________BusinessNameorResidence:_________________________________ Address:_______________________________________________TimeofAlarm:________________________ ContactName:___________________________Title:________________Phone:_________________________ PersonWritingReport:____________________OccupancyUse:______________________________________

Location ________________________________ Time ofAlarm ___________________________ Questions to askOccupants: Are there anymembers of the household feeling ill? Headache YES NO Location Time ofAlarm

_____ _____

IncidentNumber _______________ Time ofMeasurement ___________ IcidentNumber Time ofMeasurement

_____ _____

Quesion to askOccupants: A there anymembers of th usehold feeing ill? Headache YES NO

HOUR GLASS (207) 775-9915 619MainStreet,SouthPortland,ME 04106

Fatigue

YES NO

IncidentComments.PleaseNoteAll Issues. Important Information forNewPatientsofCommunityDental 1. In ord r to best serve you as a patient ofCommunityDental please complete the attached paperwork and bring ormail it to the centerwhere you are seeking services. CommunityDentalBiddeford , 57BarraRd.,Suite 3,Biddeford,ME 04005 (207) 282-1305 CommunityDentalFarmington , 131FranklinCommons,Ste I ,Farmington,ME 04938 (207) 779-2659 CommunityDentalLewiston , 177MainSt., Lewiston,ME 04240 (207) 777-7442 CommunityDentalPortland , 640BrightonAve,Portland,ME 04102 (207) 874-1028 CommunityDentalRumford , 60 LowellSt,Rumford,ME 04276 (207) 369-3600 2. On the day of your appointment, please arrive 10minutesbefore your appointment time. It is required that you bring your insurance card with you to each appointment. 3. A parentorguardian must accompany patients under 18 years of age and remain at theCenter during the length of the appointment. 4. Payment for dental services is due at the same time you receive the dental care. There is a $25 fee for any check payments returned for non-payment. 5. If you are requesting consideration for our income based sliding fees , youmust complete the sliding fee application (on page 3) and include copies of all proof of household income.Thismay include: • A copyof yourmost recentTaxReturn,currenthouseholdW-2sorpay stub(s) that includes year todate income total. • A copyof yourTANFCheck,SSI/SSDICheck,RetirementCheck,VABenefitsorBank statementofDirectDeposit for anyof the above • Alimony, child supportpayment,CityorGeneralAssistanceVoucher Proof of incomemust be updated annually. Full feeswill be applied if documentation is not receivedwith application. ACCOUNT NO. AGENT NO. PURCHASE ORDERNO. CONTRACTOR LICENSE# STATESALESTAX# CUSTOMERSTATETAXOREXEMPTNO. CUSTOMERFEDERALTAX I.D.NO. SOURCE SALESMAN I.D. 10 INSURANCEPROOFOFLOSS VEHICLE INFORMATION SOLDTO: CUSTOMER: POLICYNO: CLAIMNO: CAUSE& LOSS LOCATION VERIFIEDBY DATEOFLOSS

Nausea

YES NO

Dizziness

YES NO

Situation foundupon arrival.Please check allboxes that apply. HumanElement.

Shortness ofBreath YES NO Other ____________________________________________________ YES NO A “YES” response to any of thequestions requires andEMS evaluationby theparamedic. Do you feel better away from the house? YES NO What applianceswere on at the time of activation? _________________________________ What applianceswere in use in the last 24 hours? __________________________________ GasDetectionMeterChecklist Area of RoomLocation PPMReading Area of RoomLocation Shortness ofBreath YES NO C fusion YES NO Other _____ YES NO A “YES” respnse t any of thequestions rquires andEMS evaluationby theparamedic. Do you fel betteraway from th house? YES NO What appliancswere onat the time of activation? _____ What appliancswer i us in the last 24 hours? _ _____ GasDetectionMetrChecklist Area of RomLocation PPMReading Area of RomLocation Dba:FreeRangeFish&Lobster Phone: (207)774–8469 Fax: (207) 774–8466 FREEDOMFISH,LLC 450CommercialStreet Portland,ME04101 StraightBillofLading DELIVERING CARRIER: TO: Consignee DATE YES NO Confusion

XXXXX

Dba:MaineStreamSeafood Phone: (207) 871–9020 Fax: (207) 871–5030

DATE

FireAlarm activation intentional FireAlarm activationunintentional FireAlarm activationunknown Sprinkleractivation intentional Sprinkleractivationunintentional Sprinkleractivationunknown FireAlarmorSprinklerSystem condition.

FEDERALTAX I.D.NO.

INSTALLEDBY

ORDERTAKENBY

27-2627546

PPMReading Received subject to the classifications and tariffs in effect on the date of the issue of thisBillofLading, thepropertyasdescribedhere inapparentgoodorder,except as noted (contents and conditions of contents of packages unknown), consigned, and destined as indicated here which said carrier (the word carrier being understood throughout this contract as meaning any person or corporation in possession of thepropertyunder the contract)agrees to carry to theusualplaceof delivery at saiddestination ifonhis route,otherwise todeliver toanother carrier on the route to said destination. It ismutually agreed as to each carrier of all or any of said property over all or any portion of said route to destination and as to each party at any time interested in all or any said property, that every service to be performed hereunder shall be subject to all the bill of lading terms and conditions in the governing classification on the date of shipment. Shipper hereby certifies that he is familiarwith all of the bill of lading terms and conditions in the governing classification and the said terms and conditions are hereby agreed to by the shipper and accepted for himself and his assigns. PPMReading

Street

OutsideReading

GasDryer

TOREORDERCALL: (207) 892-1850 • MAINE LABEL&PRINTING • POBOX 938,WINDHAM,ME 04062

Destination Ship to AWB

ZipCode

HotWater Heater

FireAlarm systempartially shutdown FireAlarm system completely shutdown FireAlarm left in“trouble” condition Sprinklerpartially shutdownor impaired Sprinkler completely shutdown DryPipeSystem tripped Dry sprinkler left inawet condition Have you verified that thepropertyownerormanagerhasbeennotifiedof theproblembefore you cleared the scene? Yes o No o HasFireAlarmbeennotified of the situation, and the informationhasbeen logged into the incident? Yes o No o HasFireAlarmSystembeen restored? Yes o No o INSURANCECO: INSURANCECO: PHONENO. POLICYNAME AGENTNAME AGENTPHONE NAME ODOMETER

XXXXX

Entry

SHIPPERORCONSIGNOR

CRATE INVOICE

TOTES

OrderBy

PackedBy

PortableHeater

Portabl Heater

Furnace

_____ 21GREATREPUBLICDRIVE GLOUCESTER,MA01930 (978) 330-3051 •FAX (978) 513-8426 CUSTOMERNAME LOCATION ofTRANSACTION DRIVER Price Lbs.

IN:

OUT:

Refrigerator

Chimney Fireplace Product

Chimney

DATE

No. Packages

Extended Price

Stove /Oven

Sto /Oven

Fireplace

Stove /Hood

Garage

CODetector

BBQGrill

DEDUCTIBLE

CODetector Information ____________________________________________________________________ Make ____________________________________ Model _____________________________ Name of Individual handling theCOmeter ______________________________________________________ Officer completing the checklist _______________________________________________________________ Received by ______________________________________________________ Date: ___________________ Homeowner orTenant This checklist shall be completed for allCarbonMonoxide detector activations. The completed sheet shall be completed and returned to the office. The owner or occupant shall be given part two of the sheet CODetect Infrmation Make _____ Model Name of Individua handling theCOmeter _ Officer completing the checklist Received by _____ Date: Homeowner orTenant This checklist shall be completed for allCarbonMonoxide detetor activations. The completd eet shall be completed and returnedt th office. Th owner or occupnt shall begiven part two of thesheet CRATES PALLETS BARRELS

_____

_____ CONTAINER TOGLOUCESTER

TOCUSTOMER

BALANCE

MODEL LICENSE

YEAR VEHICLE I.D.NO.

DOORS

_____

o No ImportantBrokenAppointmentNotice Missed appointments prevent patients from getting the care they need. Community Dentalmay restrict patients from scheduling appointments if they have broken an appointment. An appointment is considered to have been broken if: 1. The patient fails to appear for the appointment, or 2. The patient arrives too late for a scheduled appointment, or 3. The patient cancels an appointmentwith less than 24hoursnotice

Signature ofOccupancyOwnerorManager: ______________________________________________

VATS

January 2012

OfficeUseonly:FollowupRequired? Yes o FollowupDate: ______________F.D.Personwho followedup______________________________

WhiteCopy toOffice CanaryCopy toCustomer

OTHER

Quantity H.D.

H.A.

ORIGINALSHIPPER

TYPE

❏ PREPAID TOTAL ➤ WHITE -OFFICE CANARY -CUSTOMER PINK -CARRIER GREEN -CARRIER BLUE -CARRIER COMMENTS: ❏ COLLECT

FREIGHT:

www.facebook.com/communitydentalmaine WORKAUTHORIZATION Iherebyauthorize theabovework tobedone togetherwith thenecessarymaterial,but request that you contact me if the costof the service exceeds the amount reflected on the invoice. ASSIGNMENTOFPROCEEDSANDAUTHORIZATIONTOPAY: Replacement or repair of the glass inmy automobilehasbeen done tomy satisfaction. I authorizemy insurance company to release policy, coverage andother information toHourGlass. I hereby authorize anddirect my insurance company topay this invoicedirectly.HourGlass and I assign any and all claims in connectionwith this automobileglass installation or repair againstmy insurance company and all policyproceedsdue for this installation or repair toHourGlass. I agree that ifmy insurer should ignore thisdirective to pay and the assignmentof thepolicyproceeds and issue payment tome that Iwill immediately forwardpayment toHourGlassby either endorsing the check that I receiveover toHourGlassorpayingHourGlass an amount equal towhat I received. If I donothave insurance coverage. I agree topay forworkmyself. IMPORTANT WARRANTYTERMS ON BACK CUSTOMER’SSIGNATURE

WhiteCopy forpropertyowner Yellow&PinkCopy forFireDepartment

www.communitydentalme.org

CheckoutourWebsite

GLOUCESTERSEAFOODPROCESSING (PLEASEPRINTNAME)

TERMS

CUSTOMER (PLEASEPRINTNAME)

CUSTOMER’SSIGNATURE

TOTALSALE

TERMS:NET30DAYS,SERVICECHARGEOF 1 1/2%PERCENTPERMONTH (18%PERYEAR)WILLBECHARGEDONOVERDUEACCOUNTS TRANSACTION ISSUBJECTTOTERMSANDCONDITIONSONREVERSESIDE

207.892.1850

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